Health inspection·February 7, 2025

Health and Safety Code 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within 24 hours. Health and Safety Code 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. Code of Federal Regulation Title 42, § 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. It was determined that the facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards Patient 5, to the California Department of Public Health (CDPH) immediately or within 24 hours after the allegation was made. The alleged verbal abuse was reported to CDPH on December 19, 2024, two days after the facility staff witnessed the verbal abuse involving a CNAS and a patient. This failure resulted in delayed investigation by CDPH and had the potential to expose the patient to further abuse. On December 23, 2024, at 8:20 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Patient 5's record indicated, Patient 5 was admitted to the facility on January 31, 2021, with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (both medical conditions that cause weakness or paralysis on one side of the body). A review of Patient 5's "History and Physical," dated December 5, 2024, indicated Patient 5 was mentally capable of understanding. A review of Patient 5’s “eInteract Change in Condition Evaluation,” dated December 19, 2024, indicated, “…VERBAL ALTERCATION…” A review of Patient 5’s “LN-(Licensed Nurse) Condition Monitoring,” dated December 23, 2024, indicated, “…PSYCHOSOCIAL MONITORING DUE TO VERBAL ALTERCATION WITH STAFF…” On December 23, 2024, at 10:10 a.m., during an interview, Patient 5 stated the Certified Nursing Assistant (CNA) assigned to him requested a CNA Student (CNAS) to assists in providing care. Patient 5 stated during the start of care he mentioned to both staff that the care for him was useless due to his body condition was not capable to improve. Patient 5 stated the CNAS told him (Patient 5) “should have been cooperative with care”, so he would be better. Patient 5 stated he did not understand what the CNAS meant, so he asked to clarify it from the CNAS and then they started exchanging inappropriate words. Patient 5 further stated, the CNAS told him "f____ off" and gave him the "middle finger". Patient 5 further stated, “I felt disrespected and was verbally abused.” On December 23, 2024, at 10:35 a.m., an interview was conducted with CNA 1. CNA 1 stated she was standing on the right side of Patient 5’s bed when she heard the CNAS stated inappropriate words to Patient 5. CNA 1 further stated, “I was shocked.” The CNA stated she reported the altercation incident to the Licensed Vocational Nurse (LVN 1) and was told that the LVN (LVN 1) would report it. CNA 1 stated the Director of Nursing (DON) talked to her after her lunch break and was told not to "worry about it" as Patient 5 would do "that" a lot. CNA 1 stated she was not asked by the DON of the details of the incident, and she assumed the LVN had already discussed it with the DON. On December 23, 2024, at 11:01 a.m., during an interview with LVN 1, LVN 1 stated CNA 1 reported witnessing the altercation involving Patient 5 and the CNAS. He stated CNA 1 reported witnessing Patient 5 being cursed by the CNAS. LVN 1 stated the CNAS should have not engaged in altercation with the patient (Patient 5), and he stated, “It’s verbal abuse.” LVN 1 stated he reported what was witnessed by CNA 1 to the DON and he thought the DON would initiate an investigation regarding the verbal abuse. On December 23, 2024, at 11:35 a.m., during an interview with the Social Service Director (SSD), the SSD stated the Ombudsman came to the facility on December 19, 2024, and the Ombudsman notified the facility staff of the abuse allegation incident involving the staff and Patient 5, which occurred on December 17, 2024. The SSD stated, any allegation of abuse should be reported immediately within 2 hours. The SSD stated the Administrator reported the incident to CDPH on December 19, 2024, (2 days from when the facility staff was initially made aware of the abuse allegation). On December 23, 2024, at 1:30 p.m., during an interview with the DON, the DON stated he received a report from LVN 1 that Patient 5 had cussed and yelled at a staff. The DON stated he thought it was the usual behavior of Patient 5, yelling at staff, so he did not check Patient 5. The DON stated he did not investigate further, and he did not report to CDPH. The DON further stated he should have reported the alleged abuse to CDPH. A review of the facility’s policy and procedure titled, “Reporting Alleged Violation of Abuse, Neglect, Exploitation or Mistreatment,” dated October 2024, indicated, “…In response to allegations of abuse…the Facility will…Ensure that all alleged violations involving abuse…are reported immediately…Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse...Ensure that all alleged violations involving abuse…are reported to…The administrator of the Facility…The state Survey Agency…Adult Protective Services…” Based on interview and record review, the facility failed to report an allegation of verbal abuse by a CNAS towards Patient 5, to CDPH immediately or within 24 hours after the allegation was made. The alleged verbal abuse was reported to CDPH on December 19, 2024, two days after the facility staff witnessed the verbal abuse involving a CNAS and a patient. This failure resulted in delayed investigation by CDPH and had the potential to expose the patient to further abuse. The failure of the facility to report the alleged abuse had a direct or immediate relationship to the health, safety, or security of the patients.